PATIENT CARE PLAN: FOR MOTHER

Patient Information: 38 year old female. G1 /T1/ Pt 0 /A0 /L0. LMP: 07/08/16. Had a Cesarean birt
twin boys. Pt is allergic to Lisinopril. Pt is a gestational diabetic. Chart states pt is obese. Vital Signs: T 98.1,
122/77, P 75, R 16, O2% 97. Urinary Catheter Indwelling removal in AM. CBG Checks PRN.

Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to

(R/T), as evidenced by (AEB).
Problem #1 Impaired Skin R/T surgery AEB Cesarean birth, surgical incision, obese, gestational
diabetes.
Desired Outcome: Incision site show no signs of swelling, redness, pain, heat or loss of
function.
Nursing Interventions Client Response to Intervention
1. Assess incision site once per shift. 1. Transverse lower abdominal incisio
Unable to visualize because it was
covered by a dressing.
2. Teach incision site care once per shift (keep 2. Pt had a waterproof dressing so sh
dressing clean, dry, wash hands) was safe to shower with the dressing

3. Encourage use of incentive spirometer Q1-2 3. Pt was very good at using her
hours. During hours awake. incentive spirometer and was able to
get it to 2500 by end of shift.
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed):
These interventions worked well. The patient was very motivated in working to
implement these interventions.

Problem #2 Abdominal distention R/T surgery AEB cesarean birth, twins, surgical incision, patien
pain level 1 on scale of 0-10, less than a day since delivery, obese.
Desired Outcome: Minimize abdominal distention and no pain on scale 0-10 throughout
shift.
Nursing Interventions Client Response to Intervention
1. Encourage early frequent ambulation. 1. Pt walked in her room throughout
the day. Pt walked in hallway around
the unit twice.
2. Tighten and relax abdominal muscles Q2H. 2. Pt had abdominal pain so this was
not a very good intervention.
3. Avoid carbonated beverages that might 3. Pt drank juice and water instead of
increase accumulation of intestinal gas. carbonated drinks.
Evaluation: These interventions worked well except intervention number two. It was to
soon to implement this intervention. Instead next time I would have the patient brace
her abdomen with her hands when she gets up to give support where her incision is.

Problem #3 Risk for constipation R/T surgery AEB post pregnancy cesarean, taking pain
medication, NPO before surgery, normal bowel function hasnt returned, pt has not had
BM since deliverer.
Desired Outcome: Pt is able to have BM by end of shift.
Nursing Interventions Client Response to Intervention
1. Encourage fluid intake 8-10 glasses of water 1. Pt had a pitcher of water next to h
during shift. bed that she sipped on through out th
day.
2. Encourage intake of foods high in fiber such 2. Talked with the patient about
as fruits and vegetables. ordering more fruits and vegetables t
help her have more fiber as she had
not had a bowel movement yet.
3. Encourage ambulation Q2H during hours 3. Pt walked in her room throughout
awake. the day. Pt walked in hallway twice
during my shift.
Evaluation: These interventions were helpful and the patient started passing gas but ha
not had a bowel movement yet. Another good intervention would have been to advoca
for a stool softener for the patient.